The impact of four dynamic, goal-steered treatment strategies on the 5-year outcomes of rheumatoid arthritis patients in the BeSt study

Abstract

Irrespective of initial treatment, an impressive improvement in clinical and radiological outcomes of RA patients can be achieved with dynamic treatment aimed at reducing disease activity, leading to 48% remission, 14% drug-free remission and sustained functional improvement. Starting with combination therapy resulted in earlier clinical improvement and less joint damage without more toxicity.

Documenting the Value of Care for Rheumatoid Arthritis, Analogous to Hypertension, Diabetes, and Hyperlipidemia: Is Control of Individual Patient Self-Report Measures of Global Estimate and Physical Function More Valuable Than Laboratory Tests, Radiographs, Indices, or Remission Criteria?

“…Improvement in physical function scores with these agents is well established. However, it remains to be documented that improvement of HAQ or Multidimensional HAQ (MDHAQ) score in an individual patient will result directly in a significant change in mortality outcomes, analogous to studies in other chronic diseases 23,24 .…”

“…The highest levels of remission reported in RA are seen in clinical trials of a treat-to-target strategy 20,21,22,23,24,25 (Table 1). However, in most series from usual clinical care, only 6-33% of patients met even the least stringent DAS28 remission criteria 17,26,27,28,29,30,31,32 (Table 1).…”

“…Among the 4 measures of the DAS28, swollen and tender joint counts were less significant, CRP was not at all significant, while patient global estimate was most significant to explain improvement in quality of life during treatment with biological therapies. Their report extends impressive contributions from the Danish community to international rheumatology, including much information about biological therapies in usual care from the comprehensive DANBIO registry 34 , and the Ciclosporine, Methotrexate, Steroid in RA (CIMESTRA) trial 24 21 Tight Control for Rheumatoid Arthritis (TICORA) trial; 65% intensive group; DAS; single-blind RCT 16% usual care group; DAS Verstappen, 2007 22 Computer Assisted Management in Early Rheumatoid Arthritis 50% intensive group; Utrecht criteria*; (CAMERA) study; open-label strategy trial 37% conventional group Utrecht criteria* Klarenbeek, 2011 23 BehandelStrategien (BeSt) or "treatment strategies" trial 23% drug-free remission Hetland, 2012 24 Ciclosporine, Methotrexate, Steroid in RA (CIMESTRA) 56%; Boolean; 78%; DAS28 Wevers-de Boer, 2012 25 Induction …”

Core Management Principles in Rheumatoid Arthritis to Help Guide Managed Care Professionals

“…A 5-year follow-up report of the BeSt trial demonstrated that all groups had good clinical outcomes, but the infliximab combination group had less joint damage as assessed by radiographs. 31 In the PREMIER study, patients with less than 3 years of disease duration were randomized to methotrexate alone, adalimumab alone, or methotrexate/adalimumab combination therapy. Early treatment with combination therapy proved superior to methotrexate alone or adalimumab alone in clinical treatment responses as well as radiographic progression of joint damage.…”

Management of Rheumatoid Arthritis: Consensus Recommendations From the Turkish League Against Rheumatism

“…It has also been suggested that modifications such as dose reduction and drug cessation be made in patients under intensive treatment and tight monitoring; however, this recommendation has not been carried out due to lack of evidence. [131,132] The most important aspect regarding this issue is the duration of remission. Reduction in the synthetic or biological DMARD dosage can be performed in cases of persistent remission, otherwise stated as remission for at least 12 months.…”